Therapeutics
Review: In benign paroxysmal positional vertigo, the Epley maneuver increases symptom resolution Clinical impact ratings:
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Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev. 2014;12:CD003162.
多多多多多夞夞
Question
Conclusion
Does the Epley maneuver resolve symptoms of benign paroxysmal positional vertigo (BPPV)?
In benign paroxysmal positional vertigo, the Epley maneuver increases resolution of vertigo symptoms compared with a sham maneuver.
Review scope Included studies compared the Epley maneuver with placebo, no treatment, or another active treatment in adults > 16 years of age with clinically diagnosed BPPV (positional nystagmus and a positive Dix-Hallpike positional test). Outcomes were complete resolution of vertigo symptoms and conversion of Dix-Hallpike test from positive to negative.
Review methods Cochrane Ear, Nose, and Throat Disorders Group trials register, MEDLINE, EMBASE/Excerpta Medica, CINAHL, AMED, Web of Science, LILACS, CAB Abstracts, KoreaMed, IndMed, PakMediNet, trial registries (Current Controlled Trials, ClinicalTrials.gov, World Health Organization), Google Scholar, and Google to Jan 2014; CENTRAL (2013, Issue 12); BIOSIS Preview and China National Knowledge Infrastructure (to May 2010); and reference lists were searched for randomized controlled trials (RCTs). MEDLINE, TRIP database, and Google were searched for systematic reviews. 11 RCTs (n = 745, age 18 to 90 y, 55% to 74% women) met the inclusion criteria, including 1 that used an alternative to the Dix-Hallpike test for diagnosis. 18 potentially eligible RCTs were excluded because of high risk for bias. 5 RCTs compared the Epley maneuver with a sham maneuver, 3 with other repositioning maneuvers (Semont, hybrid Gans, BrandtDaroff), and 1 with no treatment. 2 RCTs compared another active treatment (drugs in 1 RCT, postural restriction in 1 RCT) with vs without the Epley maneuver. 7 RCTs had follow-up ≥ 1 month, 1 at 12 months, and 1 at 48 months; 2 did not report the follow-up period. 7 RCTs reported adequate allocation concealment, 4 blinded patients, 8 blinded outcome assessors, and 8 included outcome data from all patients.
Main results The Epley maneuver was better than sham maneuvers or other control treatments for completely resolving vertigo symptoms and converting to a negative Dix-Hallpike test (Table). A single Epley maneuver was better than 1 week of Brandt-Daroff exercises for Dix-Hallpike test conversion; the Epley maneuver did not differ from the Semont or Gans maneuver at 7 days (Table).
Source of funding: No external funding. For correspondence: Dr. Malcolm P. Hilton, Royal Devon and Exeter NHS Trust, Exeter, England, UK. E-mail [email protected].
Commentary Dizziness is one of the most common symptoms in primary care, with BPPV representing about 20% of cases (1). The updated systematic review by Hilton and colleagues evaluates whether the Epley maneuver resolves vertigo symptoms in BPPV. Results showed that the Epley maneuver was better than sham maneuvers or other control treatments for completely resolving vertigo symptoms and converting to a negative Dix–Hallpike test. However, the Epley maneuver did not differ from the Semont or Gans maneuver at 7 days. Strengths of the review include choice of a subjective measure of resolution of symptoms experienced by patients as the main outcome; this is generally the most important question that patients have. In addition, the study reviewed several control treatments across a range of adult ages in various settings. Trials that compared the Epley maneuver with alternative particle-repositioning maneuvers reported conversion to a negative Dix-Hallpike test but not the primary outcome of complete resolution of vertigo symptoms. Because about 25% of symptomatic patients have little or no nystagmus (2), complete symptom resolution is the more useful outcome measure. In addition, the small sample sizes in those comparisons raise the question of whether some of the other maneuvers, such as Semont, are really equally effective. Nevertheless, the consistency of the results and their congruence with clinical experience suggest that all primary care clinicians should have the Epley maneuver as part of their therapeutic armamentarium. Alexis Carrington-Ford, MD Allan V. Prochazka, MD, MSc Denver VA Medical Center Denver, Colorado, USA
Epley maneuver vs control in adults with benign paroxysmal positional vertigo* Outcomes†
Control treatment
References
Number of trials (n)
Weighted event rates
RBI (95% CI)
NNT (CI)
Complete symptom resolution
Sham maneuver or no treatment
5 (273)
55% vs 21%
163% (82 to 281)
3 (3 to 5)
Conversion to negative Dix-Hallpike test
Sham maneuver or other control‡
8 (507)
79% vs 37%
114% (81 to 154)
3 (3 to 3)
Brandt-Daroff exercises
1 (81)
80% vs 25%
222% (84 to 462)
2 (2 to 3)
RBR (CI)
NNH
Semont maneuver§
2 (117)
76% vs 80%
5% (⫺15 to 22)
Not significant
Gans maneuver§
1 (58)
78% vs 84%
7% (⫺20 to 28)
Not significant
1. Neuhauser HK, Radtke A, von Brevern M, et al. Burden of dizziness and vertigo in the community. Arch Intern Med. 2008;168: 2118-24. 2. Kim JS, Zee DS. Clinical practice. Benign paroxysmal positional vertigo. N Engl J Med. 2014;370:1138-47.
*RBR = relative benefit reduction; other abbreviations defined in Glossary. RBI, RBR, NNT, and CI calculated from data in the review RevMan file using a fixed-effect model. †Reported at 7 days for comparisons with Brandt-Daroff exercises and Semont and Gans maneuvers. Assessment period not reported for other pooled comparisons. ‡Other control included no treatment, drugs, or postural restriction. §1 RCT used an alternative to the Dix-Hallpike test.
姝 2015 American College of Physicians JC10 ACP Journal Club Downloaded From: http://annals.org/ by a Suny Health Sciences Ctr User on 03/31/2015
Annals of Internal Medicine
17 March 2015
Review: In benign paroxysmal positional vertigo, the Epley maneuver increases symptom resolution Clinical impact ratings:
多多多多多多夞
Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev. 2014;12:CD003162.
多多多多多夞夞
Question
Conclusion
Does the Epley maneuver resolve symptoms of benign paroxysmal positional vertigo (BPPV)?
In benign paroxysmal positional vertigo, the Epley maneuver increases resolution of vertigo symptoms compared with a sham maneuver.
Review scope Included studies compared the Epley maneuver with placebo, no treatment, or another active treatment in adults > 16 years of age with clinically diagnosed BPPV (positional nystagmus and a positive Dix-Hallpike positional test). Outcomes were complete resolution of vertigo symptoms and conversion of Dix-Hallpike test from positive to negative.
Review methods Cochrane Ear, Nose, and Throat Disorders Group trials register, MEDLINE, EMBASE/Excerpta Medica, CINAHL, AMED, Web of Science, LILACS, CAB Abstracts, KoreaMed, IndMed, PakMediNet, trial registries (Current Controlled Trials, ClinicalTrials.gov, World Health Organization), Google Scholar, and Google to Jan 2014; CENTRAL (2013, Issue 12); BIOSIS Preview and China National Knowledge Infrastructure (to May 2010); and reference lists were searched for randomized controlled trials (RCTs). MEDLINE, TRIP database, and Google were searched for systematic reviews. 11 RCTs (n = 745, age 18 to 90 y, 55% to 74% women) met the inclusion criteria, including 1 that used an alternative to the Dix-Hallpike test for diagnosis. 18 potentially eligible RCTs were excluded because of high risk for bias. 5 RCTs compared the Epley maneuver with a sham maneuver, 3 with other repositioning maneuvers (Semont, hybrid Gans, BrandtDaroff), and 1 with no treatment. 2 RCTs compared another active treatment (drugs in 1 RCT, postural restriction in 1 RCT) with vs without the Epley maneuver. 7 RCTs had follow-up ≥ 1 month, 1 at 12 months, and 1 at 48 months; 2 did not report the follow-up period. 7 RCTs reported adequate allocation concealment, 4 blinded patients, 8 blinded outcome assessors, and 8 included outcome data from all patients.
Main results The Epley maneuver was better than sham maneuvers or other control treatments for completely resolving vertigo symptoms and converting to a negative Dix-Hallpike test (Table). A single Epley maneuver was better than 1 week of Brandt-Daroff exercises for Dix-Hallpike test conversion; the Epley maneuver did not differ from the Semont or Gans maneuver at 7 days (Table).
Source of funding: No external funding. For correspondence: Dr. Malcolm P. Hilton, Royal Devon and Exeter NHS Trust, Exeter, England, UK. E-mail [email protected].
Commentary Dizziness is one of the most common symptoms in primary care, with BPPV representing about 20% of cases (1). The updated systematic review by Hilton and colleagues evaluates whether the Epley maneuver resolves vertigo symptoms in BPPV. Results showed that the Epley maneuver was better than sham maneuvers or other control treatments for completely resolving vertigo symptoms and converting to a negative Dix–Hallpike test. However, the Epley maneuver did not differ from the Semont or Gans maneuver at 7 days. Strengths of the review include choice of a subjective measure of resolution of symptoms experienced by patients as the main outcome; this is generally the most important question that patients have. In addition, the study reviewed several control treatments across a range of adult ages in various settings. Trials that compared the Epley maneuver with alternative particle-repositioning maneuvers reported conversion to a negative Dix-Hallpike test but not the primary outcome of complete resolution of vertigo symptoms. Because about 25% of symptomatic patients have little or no nystagmus (2), complete symptom resolution is the more useful outcome measure. In addition, the small sample sizes in those comparisons raise the question of whether some of the other maneuvers, such as Semont, are really equally effective. Nevertheless, the consistency of the results and their congruence with clinical experience suggest that all primary care clinicians should have the Epley maneuver as part of their therapeutic armamentarium. Alexis Carrington-Ford, MD Allan V. Prochazka, MD, MSc Denver VA Medical Center Denver, Colorado, USA
Epley maneuver vs control in adults with benign paroxysmal positional vertigo* Outcomes†
Control treatment
References
Number of trials (n)
Weighted event rates
RBI (95% CI)
NNT (CI)
Complete symptom resolution
Sham maneuver or no treatment
5 (273)
55% vs 21%
163% (82 to 281)
3 (3 to 5)
Conversion to negative Dix-Hallpike test
Sham maneuver or other control‡
8 (507)
79% vs 37%
114% (81 to 154)
3 (3 to 3)
Brandt-Daroff exercises
1 (81)
80% vs 25%
222% (84 to 462)
2 (2 to 3)
RBR (CI)
NNH
Semont maneuver§
2 (117)
76% vs 80%
5% (⫺15 to 22)
Not significant
Gans maneuver§
1 (58)
78% vs 84%
7% (⫺20 to 28)
Not significant
1. Neuhauser HK, Radtke A, von Brevern M, et al. Burden of dizziness and vertigo in the community. Arch Intern Med. 2008;168: 2118-24. 2. Kim JS, Zee DS. Clinical practice. Benign paroxysmal positional vertigo. N Engl J Med. 2014;370:1138-47.
*RBR = relative benefit reduction; other abbreviations defined in Glossary. RBI, RBR, NNT, and CI calculated from data in the review RevMan file using a fixed-effect model. †Reported at 7 days for comparisons with Brandt-Daroff exercises and Semont and Gans maneuvers. Assessment period not reported for other pooled comparisons. ‡Other control included no treatment, drugs, or postural restriction. §1 RCT used an alternative to the Dix-Hallpike test.
姝 2015 American College of Physicians JC10 ACP Journal Club Downloaded From: http://annals.org/ by a Suny Health Sciences Ctr User on 03/31/2015
Annals of Internal Medicine
17 March 2015
